final exam short case
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Chief complaint
A 65year old male patient of resident farmer by occupation came to opd with a complaint of
Cough with Expectoration and right knee pain from 1 year , lower back ache, neck pain, and burning sensation of feet from 6 months.
History of present illness
Patient was apparently Assymtomatic since 1year then he developed cough with Expectoration (thick, whitish, non blood tinged, odour less sputum).
No History of fever, cold, shortness of breath, chestpain.
History of lower back ache radiating to lower limb since 6 months not associated with tingling sensation.
History of neck pain radiating to upper limb since 6 months not associated with tingling sensation.
History of burning sensation of both feet since 6 months not associated with tingling sensation, numbness.
History of right knee pain since 1yr which is increased with exertion & associated with crepitus.
Also has history of nocturia, dribbling of urine since 6 months, not associated with Polyuria, polydypsia, polyphagia.
History of past illness
No H/o trauma
K/c/o Hypertension since 6 months and he is on regular medication of Tab TELMISARTAN 40mg.
No H/o Dm, epilepsy, Tb, asthma.
Family History
No significant family history.
Personal History
Diet - mixed
Appetite - normal
Bowel and bladder movements - regular
Micturation - Abnormal (Nocturia with dribbling of urine since 6 months).
Allergies- no allergies
Addictions - drink toddy daily 2 litres
- beedi smoker daily 10 per day
Physical Examination
General
Patient is conscious, coherent, cooperative and well oriented to time and place.
Patient is moderately built and well nourished.
Pallor - absent
Icterus - absent
Cyanosis- absent
Clubbing-absent
Lymphadenopathy-absent
Edema - absent
Vitals
Temperature - Afebrile
Pulse rate - 76bpm
Respiratory rate - 16 cycles per minute
Bp - 170/90 mmhg
Spo2 - 98%
Systemic examination
Cvs
No thrills
No murmurs
S1 and S2 are heard
Respiratory system
Inspection- I have taken patient consent and examined the patient in sitting position.
Upper respiratory tract- oral cavity, nose & orophayrnx is normal .
Chest is bilaterally symmetrical & elliptical in shape
Position of trachea is central.
Respiratory movements appear equal on both sides & it is Abdominothoracic type.
No scars, veins, sinuses, visible pulsations.
Palpation-
All inspectory findings are confirmed
No local rise of temperature
No tenderness
Trachea is in Central position
Percussion-
Right . Left
Supraclavicular Resonant. R
Infraclavicular. . R R
Mammary. . R R
Axillary. R R
Infra axillary. R R
Suprascapular. R R
Interscapular. R R
Infrascapular R R
Auscultation-
Right. Left
Supraclavicular. NVBS NVBS
Infraclavicular. NVBS NVBS
Mammary. NVBS NVBS
Axillary. . NVBS NVBS
Infra axillary. NVBS NVBS
Suprascapular. NVBS NVBS
Interscapular. NVBS NVBS
Infrascapular NVBS . NVBS
Abdomen
Shape of the abdomen - normal
Tenderness- no
Palpable mass - no
Hernial orifices- normal
Liver & spleen are not palpable
Bowel movements - present
No dilated veins, scars, sinuses.
Cns
Patient is conscious, coherent, cooperative and well oriented to time & place
Speech - normal
No signs of meningitis
Memory intact
Motor and sensory system - normal
No kerning sign
Provisional diagnosis
Cough under evaluation
Lower back ache under evaluation
Ankylosing spondylosis
Treatment
Tab ultracet -37. 5 mg tramadol HCL
-325mg acetaminophen
Tab pregabalin 75mg
Syp Ascoryl 10ml
Tab Telma 40mg
Tab pantop 40mg
Tab shelcal 500mg
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